Hydocodone Combination Products Will Switch to C2 Status

Maybe I’m just getting to be an older and more cynical pharmacist?  Maybe I can’t see the merits of certain decisions?  Maybe there is value to changing hydrocodone combination products (HCPs) to C2 status?  Or maybe, I have a valid concern that this is the wrong way to handle a real problem.

Starting October 6th, 2014 chronic pain patients and pharmacists will notice a significant change that will impact both groups.  The decision has been made to change the status of hydrocodone combination products from C3 to C2 status.  The move will further restrict legal access to this group of medications and put them on the same level of control as other C2 medications such as oxycodone.

The natural question to ask is will this do any good?  Will it make an impact on the abuse problems we now face in the United States?  Or worse, will it become a burden for chronic pain sufferers who need access to these medications?

I think the idea needed to be considered.  The drug abuse problem in America has gotten that bad.  Even bad ideas that might address the problem should be considered.  But again, I am referencing “bad ideas” to describe this change.  That should clear up how I personally feel on the matter.

I would have looked to see if the idea was already working anywhere in the country already.  The problem, only New York previously changed HCPs to C2 status on their own and that just happened last year.  If there is any significant data showing it’s impact on the abuse problems of HCPs in New York, I can’t find it.  If New York had years of data proving it helps, I might feel differently.

One can only look at the abuse problems a drug like oxycodone has despite it’s C2 status and wonder if drug classification is the root problem.  Of course, you can’t exactly determine how much worse things might be for a drug like oxycodone if it were C3 status.  But it’s not a good sign to look at the peers in this classification group to validate this decision.

Unless prescribers really start to evaluate their own prescribing habits things will not significantly change.  Unless we look at our drug culture that actively promotes “a pill is the answer” mentality for anyone with a problem, things will not change.

And what is worse, the law of unintended consequences suggests that legitimate chronic pain sufferers will be impacted more by this change than anyone else.  The last thing we need is to make it more difficult for people who are actually suffering from pain to get relief.

It will be interesting to see what impact this change will have on HCPs in the near future.  Will those products be avoided now by prescribers?  Will patients ask for alternatives?

I wonder if prescribers will try tramadol or codeine combination products more often now to avoid the new C2 restriction on HCPs?  Will prescribers that normally would have considered hydrocodone combination products simply bump some patients up to oxycodone products?

I have seen anecdotal evidence in my area that there has been an uptick of HCP scripts in recent weeks.  I wonder if pain patients are “stocking up” before the switch in status?  I’d be curious to hear if anyone else has noticed similar trends recently.

I’d like to be on board with this idea.  I’d like to say that everything will be fine starting 10/6/14 and that hydrocodone abuse will start a nice gradual decline after it become C2.

But the reality is I can’t help but feel that this will not do what it intended to do.  We will continue to have a serious drug abuse problem even after early October.  This will not change that fact.  And that leaves us with the real question of the day: what can be done that will actually work?

The Redheaded Pharmacist

“Sometimes, you just have to get angry!”

    It all started with an email I received from another pharmacist.  That email left me wondering about questions I felt I couldn’t answer. 

    Someone who has been a pharmacist for a lot longer than I have sent me an email with some comments and questions about the state of our profession.  His concerns and frustrations have been echoed here and elsewhere by many other pharmacists. 

   He wrote about the idea of the unionization of pharmacists and his personal reservations with unionizing.  But he did mention that something needed to be done. 

    He also voiced his frustration with the organizations that represent our profession.  He said that we needed to unite in some meaningful way as pharmacists.  Sound familiar?  It should. 

   I sat on this email for several days without responding.  I didn’t know what I could say.  I felt a lot of the same concerns he did.  And sadly, I have fewer answers than questions.

   I showed the email to my wife and I told her I didn’t know how to respond.  “What do I need to tell him?”  I asked the question as if I was completely lost.  In some ways, I am. 

   She looked at what this pharmacist wrote and then she said to me “sometimes, you just have to get angry!”  She knows my frustations.  She knows the challenges I face at work.  I couldn’t have said it better myself. 

    Her comment got me thinking.  Anger is a good motivator.  It spurs action like no other human emotion. 

    The problem with anger is that it can lead to irrational behavior. We don’t need irrational behavior pushing our profession forward.  We need organized and thoughful responses to any problem we might face. 

    Sometimes it does seem like the organizations that are supposed to have our backs don’t really care or are focused on non-essential issues.  They want to push us towards the future.  But sometimes we just need help with the present.

    I’ve explained before that I don’t think unionization is the answer for the profession of pharmacy.  I won’t bore you with my reasoning.  Let’s just assume I’d vote no if it came to that. 

    But the fact that so many pharmacists entertain the idea tells me something is wrong.  Power and control are important.  And many pharmacists feel like they’ve lost both at work. 

    I also think the big organizations like the APhA do more for our behalf than they get credit.  But having said that, couldn’t they do more?  Couldn’t they voice our concerns a little louder? 

    I think a code of conduct for retail pharmacy operators is in order.  It could include a basic set of standards for working conditions, staffing, and expectations.  The big organizations could become involved in this.

    But we all as individual pharmacists need to get more involved ourselves.  And that might even include joining the organizations that we sometimes question.  They can’t be expected to be the strong voice we need if we aren’t there to support them. 

   I’d also lean harder on politicians.  Like it or not, they have power.  And if they don’t understand how bad working conditions in retail pharmacies might endanger the public, they won’t be pressed to address the issue. 

    I don’t know exactly what it’s going to take to make things better for the profession of pharmacy.  I do know that something needs to be done. 

   As my wife said “sometimes, you just have to get angry.” For many of us, that time has already arrived.  The question then remains: what are you going to do about it?

The Redheaded Pharmacist

Herd Mentality

   It would be nice to get some independent thinkers in management positions at some of the large retail pharmacy chains.  Unfortunately, they are either non-existent or outnumbered by the herding masses of group think. 

   One of the more frustrating things about working for a large company that operates multiple pharmacies is the concept of corporate level herd mentality.  Why do all major pharmacy chains copy bad ideas from their peers in the industry? 

    Just because one company comes out with a ridiculous pricing structure like Walmart’s $4 generic list doesn’t mean the rest of the community pharmacy world is somehow required to follow suit.  Let the bad ideas and the companies that birth them fail on their own.  The rest of us should be able to safely watch the implosion from a distance.

    But reality tells us that if Walmart or whomever thinks blister packs is a good idea, we all somehow end up with long flat packages of 30 pills that our elderly patients constantly complain are difficult to open.  Why is that?

   Chains don’t dare contemplate being different because of a fear of losing precious revenue dollars.  But what if the ideas they so deperately want to mimic actually hurt the bottom line?

    My company clings to their $25 transfer coupon promotion like our future depends on it despite obvious flaws to the program.  Have you ever calculated how much front end merchandise a customer needs to buy to make up for the $25 you just gave away at the pharmacy?  The numbers are staggering and unrealistic.  

    That’s why the recent surprise CVS announcement that they are going to phase out cigarette sales from their stores by this October interests me so much.  I can’t help but wonder what the other big chains will do in response. 

    Independent thinking is a dying breed in the business world.   But if the unique challenges of community pharmacy should teach us one thing, wouldn’t that lesson be a willingness to look beyond the white noise of our competitive landscape to find better ways to serve our patients and customers? 

    I guess I just get frustrated by the herd mentality on this kind of grand scale.  And I admire the small independent pharmacies that think outside the box and implement new ideas out of a necessity to compete with their bigger competitors. 

    The herd mentality has resulted in bad ideas surviving way past their expiration date.  And in my mind it’s time to move on to bigger and better things in our world of community pharmacy.

     Are you ready to put on your thinking caps and come up with some original ideas?  The better question might be will anyone hear your thoughts through all of the noise of the herd?  I sure hope so!

The Redheaded Pharmacist

The Truth Slips Out

      I had an interesting conversation with an executive at work the other day.  And the words that came out of her mouth were quite telling.

      It happened a couple of weeks ago.  The flu shot administration frenzy was just starting to hit us full steam. 

      The store I was working at that day received a surprise visit.  A vice president within one of my company’s many divisions stopped by during one of her visits to our area. 

      I was working with another pharmacist at the time and the two of us chatted with this VIP about the flu hitting our area early this year and how we were busy with flu shots. 

      After I made a comment about local emergency departments already seeing cases of the flu, She said what I feared upper management thought all along.  She told the three of us working that day “I hate to say it, but the flu is good for business!” 

      I stopped what I was working on at the time and glanced back at the other pharmacist on duty.  The glance he gave me back must have been the same glare I reciprocated to him. 

      We didn’t say a word, and soon after this executive was off to do whatever else those people do with their day.  But when she was gone, the other pharmacist complained to me about her sentiment.

      It does seem cold and callous to view the seasonal flu outbreaks as a business opportunity.  In her defense, I’m sure she didn’t mean what she said the way it came across to those of us that heard the comment.  At least I hope not.

      But the reality is that community pharmacy is now dominated by a handful of large players.  They tend to look more at spread sheets and numbers and forget the fact that people are sick and we are not merely numbers on a report but actual people. 

      I’m not going to celebrate an illness that claims thousands of lives every year even if it brings big business to my employer and my profession.  I recognize that getting the flu is a miserable experience.  And it could even kill you. 

     Most of the time the official words that come from large community pharmacy chain executives regarding the flu reference serving the community or supplying a needed vaccination service.  Their messages are as prepared as your average politician’s public statements.

      But on that day, one executive let slip how I suspect many retail pharmacy executives really feel about the flu.  The reality is that the flu spells big business for community pharmacies.  And that business translates into big profits. 

      What bothers me the most about what this executive said was the company I was with at the time.  I was working with a pharmacist who was relatively new to my employer.  I can’t imagine what his thoughts were regarding his new employer after hearing comments like that from one of our divisional vice presidents. 

     This really demonstrates the battle community pharmacists have with their employers about perspective.  Pharmacists are trained to think clinically, and our focus is more patient care oriented. 

     Large corporations are more business oriented.  They are more concerned with the Xs and Os of profits, inventories, and balance sheets. 

     And while it’s true pharmacists can’t simply ignore the business side of retail pharmacy, isn’t it also true that the chains can’t disregard the human aspect of our business?  This battle to balance opposing reference points plays out day after day in pharmacies eveywhere. 

      I hope that particular vice president can look past the dollars and realize that the flu is a serious public health threat.  And I hope pharmacists can balance their patient focused backgrounds with the need to keep a business running efficiently enough to keep its doors opened and everyone’s job secure. 

     Sometimes the truth hurts though.  Even if it slips out unintentionally in the form of a passing comment. 

The Redheaded Pharmacist

Think Bigger

       It’s amazing how your perception of the profession of pharmacy changes as you gain experience.  You start to see things you didn’t notice before.  Or maybe, you notice things you just didn’t want to see before? 

       I remember earlier in my career.  When I first became a licensed pharmacist, the job would occasionally keep me up at night. 

       Today the stresses of community pharmacy can still cause me sleepless nights.  But the root causes of those fits of insomnia have expanded. 

       When I first started checking prescriptions as a licensed pharmacist my focus was very internal.  I was so worried about making a misfill or harming a patient.  A couple of times I actually called back to work just to verify some little detail with a particular prescription was correct. 

       The funny thing about that admission is the fact that the veteran pharmacist I worked with at the time understood.  I wasn’t treated as if I was some kind of anomaly.  What I was going through was expected as a new practitioner. 

       For me, it was so easy to put on my blinders and think about my own little pharmacy world.  I rarely expanded my focus to anything bigger than my own career.   I was happy to be employed and to experience positive cash flow!

       When I first started working I didn’t much consider all of the outside forces that could impact my ability to do my job.  You could call it the delusion of control.  I only needed to make sure my prescriptions were correct and that my pharmacy wasn’t making mistakes.  My patients were doing fine so wasn’t the whole profession OK?  

       It was so easy to get caught up in the work of being a pharmacist that I forgot about what it meant to be one in the first place.  I didn’t see the bigger picture.  I didn’t think bigger than myself. 

       The good news is that after you get some experience, some of the anxiety about making mistakes subsides.  You gain confidence in your abilities and knowledge.  Misfills seem more likely a result of carelessness as much as a personal inability or shortcoming.  You start to question the factors that could result in a mistake or even encourage them.

       And then you realize there is a bigger picture to the profession.  You realize that forces much bigger than yourself are working in ways you never dreamed or feared to influence your ability and even desire to do your job. 

       It is this realization that has made me think a little differently now.  I pay attention to the news more than before.  I try to stay informed and even dare to contribute in some small ways.  I see the connections that things can have with my ability to do my job.  And it’s because I bother to look.

       That’s really one of the only pieces of advice I can give to pharmacy students.  Learn to look at the profession with lenses bigger than yourself.  It will serve you well as the forces of change impact your pharmacy career. 

       I think we’d all be better served thinking a little bigger than ourselves.  The issues and challenges we face will be much easier to tackle as a group project rather than a bunch of independent studies. 

       It’s time to see the forest AND the trees.  It’s time to think big, and then think bigger. 

The Redheaded Pharmacist

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